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Most Health Insurance is Accepted.
-CHP -Kaiser -ACN -Regence BCBS -Healthways -Premera -First Choice -Uniform Medical-
(No longer accepting ASH insurance)
 
Health Insurance coverage must be verified before treatment is rendered .
Please fill out the form below & I will respond as soon as possible. 
All information is kept confidential and is used only to check Health Insurance coverage.
Please give a 24 Hr. notice if you need to cancel an appt. Regretfully, you will be charged the full amount if notice is not given.
First Name
Last Name
Contact Phone #
E-Mail Address
How do you prefer to be contacted?
Phone
E-Mail
Either is fine
Date of Birth MM/DD/YYYY
Street Address
City
State
Zip Code
How did you hear about Experience Relief Massage? Where you referred by someone? If yes, who? :)
The following information can be found on your Health Insurance Card:
Health Insurance Name
Health Insurance Contact Number (for Providers or Customer Service)
ID Number (may start with letters followed by numbers)
Group Number
What are your current pain symptoms/complaints?
What appointment time would work best for you? Mon-Fri 11am-7pm
Please write any questions or concerns you may have in the box below.